MO-9551_40983_CA_UST-61_20200201_24-Hour Release & UST Leak Reporting Form

UST-61
24-Hour Release and UST Leak Reporting Form.
For Releases This form should be completed and submitted to the UST Section's regional office following a known or suspected release from
an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or
in NC
suspected release
(DWM USE ONLY)
Suspected Contamination? (Y/N)
Facility ID Number
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N)
Date Leak Discovered
Received On Received By
Confirmed Soil Contamination ?(Y/N)
Comm/Non-Commercial?
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N)
Reg/Non-regulated?
Region
Free Product? (Y/N) If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name:
Address:
County:
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town:
Zip Code:
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees):
Longitude (decimal degrees) :
Obtained by:
❑GPS
Briefly describe suspected or confirmed release: (including but not limited to: nature of release, date of release, amount
of release, amount of free product present and recovery efforts, initial responses conducted, impacts to receptors)
❑Topographic map
❑GIS Address matching
❑Other
❑ Unknown
Describe location:
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑Release Detection Equipment or Methods ❑Visual/Odor ❑Groundwater Contamination
❑During UST Closure/Removal
❑Water in Tank ❑Surface Water Contamination
❑Property Transfer
❑Water Supply Well Contamination ❑Other (specify)
SOURCE OF CONTAMINATION
Source of Release
Cause of Release Type of Release Product Type Released
(Check primary source)
(Check primary cause) (Check one) (Check primary product type released)
❑ Tank
❑ Spill ❑ Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ Piping
❑ Overfill ❑ Non -Petroleum Kerosene Blend
❑ Dispenser
❑Heating Oil ❑ Vegetable Oil 100%
Corrosion Both
❑❑
❑ Other Petroleum ❑ E10 - E20
❑ Submersible Turbine Pump
❑Physical/Mechanical
❑ Delivery Problem
Location Products
Damage ❑ E21 - E84
(Check one) Metals
❑
❑ Install Problem ❑ E85 - E99
❑ Spill Bucket
❑ Other Inorganics
❑ Other [-]Facility ❑Ethanol 100%
❑ Other
❑ Other Organics
❑ Unknown ❑Residence ❑ E01 - E09
❑ Unknown
❑Other
Definitions presented on reverse
Definitions presented on reverse
Ownership
1. Municipal 2. Military 3. Unknown
4. Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3.
Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/19) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes 2. No 3. Unknown
Number of Water Supply Wells Affected
Water Supply Wells Contaminated:
1.
2.
3.
(Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
UST Owner/Company
UST SYSTEM OWNER
Point of Contact
Address
City
State
Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST Operator/Company
Address
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident
Company
Telephone Number
Title
Address
Date
UST Form 61 (02/19)
Page 2 of 2
Definitions of Sources
Tank: means the tank that stores the product and is part of the underground storage tank system
Piping: means the piping and connectors running from the tank or submersible turbine pump to the dispenser or other end -use equipment (Vent, vapor recovery, or fill
lines are excluded.)
Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above
the shear valve)
Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the tank sump), the line leak detector, and the piping that
connects the submersible turbine pump to the tank
Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with this source are spills and overfills.)
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill: use this cause when a spill occurs (e.g., when the delivery hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser)
Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut off at the dispenser)
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose fittings, broken
components, and components that have changed dimension)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is determined to have occurred specifically because the UST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined

RE
BETHEL WORSHIP CENTER
(420 E. 15TH STREET)
APARTMENT BUILDING
(1204-1226 N. CALDWELL STREET)
�• GP�RESTAURAN\SB-19
CONSTRUCTION)
<
i AS
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1
'n1 HUNTER AUTO & WRECKING >/
SERVICE
(1107 & 1111 N. DAVIDSON STREET
RETAIL
BUILDING
e
GRAVEL
PARKING
AREA
I LVAGED
VEHICLES
APARTMENT BUILDINGS
(525 & 535 E. 15TH STREET)
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PJ\05
T
HUN1IR AUTO & ECKING -j
SERVICE 4�
(1114 N. DAVIDSON STREE
LEGEND
SITE PROPERTY BOUNDARY
PARCEL BOUNDARY
STREAM
<cl 0 DUMPSTER ENCLOSORE
. j
��y Q POLE -MOUNTED TRANSFORMER
CLOSED -IN -PLACE HEATING OIL UST
�j SOIL SAMPLE LOCATION
NOTE
�A AERIAL PHOTOGRAPH OBTAINED FROM MECKLENBURG
COUNTY GIS, DATED 2019.
PELICAN'S SNOBALLS N
(1200 N. DAVIDSON STREET)
APPROXIMATE
0 80 160
SCALE IN FEET
TITLE
SITE AND SAMPLE LOCATIONS MAP
PROJECT FORMER RESIDENCE AND RETAIL BUILDING
510-516 E. 15TH STREET AND
1138 N. CALDWELL STREET
CHARLOTTE NORTH CAROLINA
2923 100
hart hiekman Clatme, North Carolina 3
Charlotte, North Carolina 28203
704-586-0007(p) 704-586-0373(f
SMARTER ENVIRONMENTAL SOLUTIONS License # C-1269 / #C-245 Geology
DATE: 12-11-19
REVISION NO. 0
JOB NO. CCR-003
FIGURE NO. 2

Beverly, Trudy
From: Beverly, Trudy
Sent: Monday, February 3, 2020 6:32 AM
To: Bo Cappleman
Cc: Joe McLean
Subject: RE: [External] UST Release Reporting Form - Area 15 Retail Property
Thank you for the information.
Have a great day,
Trudy
5Qi i K. M
�nment�l 4w ��
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everlykncdenn gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: ht_pt s://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httos://dea.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-ais-mans
File Review Procedures:
hops://deq.ne. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
bit.ps://deq.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
https:Hfiles.nc. gov/ncdegfWaste%2OManagement/D WM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%2OMemo%20UPdate.pdf
https:Hfiles.nc.gov/ncdeq/Waste%20Management/DWM/ JST/Corrective%2OAction/UST°/a20file%20names%20for°/`2OLaserfiche.docx
From: Bo Cappleman [mailto:[e-mail]]
Sent: Saturday, February 1, 2020 4:38 PM
To: Beverly, Trudy <[e-mail]>
Cc: Joe McLean <[e-mail]>
Subject: [External] UST Release Reporting Form - Area 15 Retail Property
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to [e-mail]
Hi Trudy,
Please see the attached 24-Hour Release & UST Leak Reporting Form for a heating oil release that was identified
at the Area 15 retail property located at 510-516 E. 151" Street and 1138 N. Caldwell Street in
Charlotte. Property ownership was recently transferred to CCRP Area 15 LLC, which intends to seek risk -based
regulatory closure through filing an alternate Notice of Residual Petroleum that will establish a soil restriction

area and prohibit groundwater use at the property. Municipal water supply is available in the site area, and no
water supply wells have been identified within at least 200 ft of the heating oil UST.
A formal report that documents the soil sampling is forthcoming. Please let me know if you have any questions
or see any issues with the plan to achieve regulatory closure.
Regards,
Bo Cappleman, PG, Due Diligence Manager
Hart & Hickman, PC
2923 S Tryon Street, Suite 100 • Charlotte, NC 28203
Direct: 704-887-4623 • Mobile: [phone]
www.harthickman.com I U 0